By Counterforce Health Team in Ocrevus (ocrelizumab) —

Do You Qualify for Ocrevus (Ocrelizumab) Coverage by Cigna in New York? Complete Decision Tree & Appeals Guide

Answer Box: Ocrevus Coverage by Cigna in New York

Yes, you likely qualify if you have confirmed relapsing or primary progressive MS and have tried/failed at least one disease-modifying therapy. Cigna requires prior authorization through CoverMyMeds or fax (855-840-1678) with 5-day processing. First step today: Contact your neurologist to request the Ocrevus CCRD Prior Authorization Form and gather your HBV screening results. If denied, New York's external appeal through DFS has strong patient protections with binding decisions.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible
  4. If You're Possibly Eligible
  5. If You're Not Yet Eligible
  6. If You're Denied: Appeal Path Chooser
  7. Decision Tree Visual Summary
  8. Cigna-Specific Requirements
  9. New York External Appeal Process
  10. Common Denial Reasons & Solutions
  11. FAQ
  12. Resources & Next Steps

How to Use This Guide

This decision tree helps you determine your likelihood of getting Ocrevus (ocrelizumab) covered by Cigna in New York. Work through each section in order—your answers will guide you to the right next steps.

What you'll need handy:

  • Your Cigna member ID and plan documents
  • MS diagnosis records and MRI reports
  • List of previous MS medications tried
  • Recent lab results (especially hepatitis B screening)
Note: This guide covers Cigna commercial plans. Medicaid and Medicare Part D have different processes.

Eligibility Triage: Do You Qualify?

Step 1: Diagnosis Confirmation

✓ Likely Eligible if you have:

  • Confirmed relapsing forms of MS (clinically isolated syndrome, relapsing-remitting MS, or active secondary progressive MS)
  • OR primary progressive MS
  • Documented via MRI showing demyelinating lesions consistent with McDonald criteria

Step 2: Prior Therapy Requirements

✓ Likely Eligible if you've experienced:

  • Inadequate efficacy with at least one disease-modifying therapy (DMT)
  • OR significant intolerance to first-line treatments
  • OR have highly active/aggressive MS with rapid progression

? Possibly Eligible if:

  • You're newly diagnosed but have highly active disease
  • You've tried some treatments but documentation is incomplete

Step 3: Safety Screening

✓ Required for all patients:

  • Hepatitis B surface antigen (HBsAg) test
  • Hepatitis B core antibody (anti-HBc) test
  • Complete blood count and immunoglobulin levels
  • Up-to-date vaccinations (completed ≥4 weeks before treatment)

⚠️ Not Yet Eligible if:

  • Active hepatitis B infection (HBsAg positive) without antiviral treatment
  • Severe active infection
  • Live vaccines needed within 4 weeks of planned treatment

If You're Likely Eligible

Document Checklist

Gather these items before submitting your prior authorization:

Clinical Documentation:

  • MS diagnosis confirmation with ICD-10 code G35
  • MRI reports showing gadolinium-enhancing lesions
  • EDSS scores (if available)
  • Documentation of prior DMT failures or intolerances
  • Current neurological status assessment

Laboratory Requirements:

  • HBsAg and anti-HBc results
  • HBV DNA if either HBsAg or anti-HBc positive
  • Complete blood count
  • Immunoglobulin levels
  • Vaccination records

Administrative Forms:

Submission Path

  1. Electronic submission (fastest): Use CoverMyMeds - 5 business day processing
  2. Fax alternative: (855) 840-1678 - up to 15 days processing
  3. Expedited review: Call (800) 882-4462 for urgent cases

If You're Possibly Eligible

You may need additional documentation or testing. Here's what to request from your healthcare team:

Tests to Request

  • Comprehensive MRI: Brain and spinal cord with gadolinium
  • CSF analysis: If diagnosis needs confirmation
  • Detailed treatment history: Documentation of all prior MS therapies
  • EDSS assessment: Formal disability scoring

What to Track

  • Disease activity markers (new lesions, relapses)
  • Response to current treatments
  • Side effects or intolerances experienced
  • Functional decline or progression

Timeline to Re-apply

Most insurers allow resubmission once additional documentation is available. Plan for 2-4 weeks to gather comprehensive records, then resubmit through the same prior authorization process.

If You're Not Yet Eligible

Alternative Treatments to Discuss

If you don't meet initial criteria, consider discussing these options with your neurologist:

First-line DMTs that may satisfy step therapy:

  • Interferon beta preparations (Avonex, Betaseron, Rebif)
  • Glatiramer acetate (Copaxone, Glatopa)
  • Dimethyl fumarate (Tecfidera)
  • Teriflunomide (Aubagio)

Preparing for Exception Requests:

  • Document why first-line treatments are contraindicated
  • Gather evidence of rapidly evolving severe MS
  • Consider peer-to-peer review with Cigna medical director

When Step Therapy May Be Waived

Cigna may approve Ocrevus without prior DMT failure if you have:

  • Contraindications to first-line therapies
  • Highly active MS with frequent relapses
  • Rapidly accumulating disability

If You're Denied: Appeal Path Chooser

Level 1: Internal Appeal with Cigna

Timeline: File within 180 days of denial notice Processing: 30 days (72 hours for expedited) How to file: Written appeal to address on denial letter

Include in your appeal:

  • Original denial letter
  • Updated medical records showing disease progression
  • Peer-reviewed literature supporting Ocrevus use
  • Medical necessity letter from neurologist

Level 2: Peer-to-Peer Review

When to use: If denied for medical necessity How to request: Call (800) 882-4462 Timeline: Can be done during or after internal appeal Participants: Your prescriber and Cigna medical director

Level 3: New York External Appeal

Timeline: File within 4 months of final internal denial Cost: $25 (waived for Medicaid/financial hardship) Decision timeline: 30 days standard, 72 hours expedited Authority: New York Department of Financial Services

Key advantage: Decision is binding on Cigna and has high success rates for well-documented cases.

Decision Tree Visual Summary

MS Diagnosis Confirmed? 
├─ Yes → Prior DMT Tried/Failed?
│  ├─ Yes → HBV Screening Complete?
│  │  ├─ Yes → LIKELY ELIGIBLE → Submit PA
│  │  └─ No → Complete screening → Then submit
│  └─ No → Highly Active MS?
│     ├─ Yes → POSSIBLY ELIGIBLE → Request exception
│     └─ No → Try first-line DMT → Document outcome
└─ No → Confirm diagnosis → Get MRI/CSF → Restart process

If Denied:
Internal Appeal (180 days) → Peer-to-Peer → External Appeal (4 months)

Cigna-Specific Requirements

Coverage Criteria

According to Cigna's policy, Ocrevus is approved for:

Indication Requirements
Relapsing MS Prior DMT failure OR highly active disease
Primary Progressive MS Confirmed diagnosis with imaging evidence
Both forms Complete HBV screening and vaccination status

Specialty Pharmacy Requirement

Cigna typically requires Accredo Specialty Pharmacy for Ocrevus fulfillment. Your prescriber can e-prescribe directly (NCPDP 4436920) or fax to 888-302-1028.

New Coverage: Ocrevus Zunovo

As of December 2024, Cigna added coverage for Ocrevus Zunovo (subcutaneous formulation), though prior authorization is still required for both IV and subcutaneous forms.

New York External Appeal Process

New York offers some of the strongest patient protections in the nation for insurance appeals.

Filing Requirements

  • Form: New York State External Appeal Application
  • Timeline: 4 months from final internal denial (60 days for providers)
  • Fee: $25 (waived for Medicaid enrollees or financial hardship)
  • Required: Physician attestation form

Decision Timelines

  • Standard appeals: 30 days
  • Expedited appeals: 72 hours (24 hours for non-formulary drugs)
  • Qualification for expedited: Serious jeopardy to health, hospitalization, or ongoing treatment

Success Factors

Based on New York's external appeals database, successful appeals typically include:

  • Thorough medical necessity documentation
  • Evidence of prior treatment failures
  • Current clinical guidelines supporting the treatment
  • Specialist attestation of medical necessity
From our advocates: In our experience, New York external appeals for specialty MS drugs succeed in approximately 70-80% of cases when comprehensive medical documentation is provided, including evidence that the patient has met step therapy requirements and that the medication is medically necessary for their specific MS phenotype.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"No confirmed MS diagnosis" Provide diagnostic workup MRI reports, CSF analysis, McDonald criteria documentation
"Insufficient prior therapy" Document DMT failures Treatment records showing inadequate response/intolerance
"Missing safety screening" Complete required testing HBV panel, immunoglobulin levels, CBC with differential
"Step therapy not met" Request medical exception Clinical rationale why first-line therapies inappropriate
"Not medically necessary" Strengthen clinical case Updated MRI showing progression, EDSS scores, specialist letter

FAQ

Q: How long does Cigna prior authorization take for Ocrevus in New York? A: Standard electronic submissions through CoverMyMeds take 5 business days. Fax submissions can take up to 15 days. Expedited reviews are available for urgent cases.

Q: What if Ocrevus is non-formulary on my Cigna plan? A: You can request a formulary exception with clinical justification. If denied, New York's external appeal process provides an independent review with binding decisions.

Q: Can I request an expedited appeal in New York? A: Yes, if delay would seriously jeopardize your health or if you're hospitalized. Expedited external appeals are decided within 72 hours (24 hours for non-formulary drugs).

Q: Does step therapy apply if I tried DMTs outside New York? A: Yes, prior treatment history from other states counts if properly documented. Ensure your neurologist includes comprehensive treatment records in the prior authorization.

Q: What's the difference between Ocrevus and Ocrevus Zunovo for coverage? A: Both require prior authorization with Cigna. Zunovo (subcutaneous) may have additional requirements for home administration training and safety monitoring.

Q: Who can help me with my Cigna appeal in New York? A: Community Health Advocates provides free assistance at 888-614-5400. They can help navigate both internal appeals and external review processes.

Resources & Next Steps

Immediate Action Items

  1. Contact your neurologist to request prior authorization submission
  2. Gather required documents using the checklist above
  3. Complete HBV screening if not already done
  4. Submit via CoverMyMeds for fastest processing

Official Resources

Getting Additional Help

If you're struggling with the prior authorization or appeals process, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex coverage requirements by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific policies.

For immediate support with your Cigna coverage in New York, Community Health Advocates offers free consultation and can assist with both internal appeals and external review submissions through the New York Department of Financial Services.

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For official appeals assistance in New York, contact Community Health Advocates at 888-614-5400 or the New York Department of Financial Services.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.